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High-Efficiency Clothes Washer Rebate Application Form Offer available July 1, 2015 thru June 30, 2016 and subject to fund availability Mail to: Water Conservation Program PO Box 642 Modesto, CA 95353 For Questions, visit www.modestogov.com/SaveWater , call [PHONE REDACTED], or email [EMAIL REDACTED] Account information (Please Print Clearly) Applicant's First Name Last Name Account Number Installation Address City Zip Telephone Number How did you hear about the rebate? Mailing Address (If different from above) City State Zip Telephone Number New Qualifying High Efficiency Clothes Washer Information Brand Model # Cubic Ft Water Factor (Must be 5.0 or less) Store Name Store Telephone Purchase Price (w/o tax) Store Location: Purchase Date Installation Date Rebate Agreement – Release of Liability The City of Modesto, in its sole discretion, may deny any application that does not meet requirements, which can be obtained by reading the Program Guidelines and conditions. The undersigned agrees to allow the City of Modesto to inspect all properties participating in the High Efficiency Washer Rebate Program. The City does not guarantee the performance of any clothes washer; or installation to be free of defects, the quality of the workmanship, or the suitability of the premises for the clothes washer installation. Installation of qualifying clothes washers may not result in lower energy bills or water bills. The undersigned further agrees to hold harmless the City of Modesto against loss, damages, expense and liability (including court, expert and attorney fees) resulting from the loss, destruction or damage of property or personal injury arising out of or in any way connected with installation of a clothes washer. The City reserves the right to alter or terminate this program at any time without prior notice. Funding this rebate program is limited to available resources. Rebates are processed on a first come, first served basis and will only be processed until funds are depleted. The undersigned states that this qualifying high efficiency clothes washer was purchased new at retail price and installed at the address indicated for personal use and not for resale. By signing this form I agree that I have read, understand, and agree to the terms and conditions of this rebate program, including the Program Guidelines and Condition for Participation Section. Customer Signature Date ---PAGE BREAK--- Program Guidelines and Participation Section For more information and for complete program details, contact the Water Conservation Program at [PHONE REDACTED], email: [EMAIL REDACTED], or visit www.modestogov.com/SaveWater Who Qualifies? • City of Modesto Water residential customers who have existing single or multi-dwelling receiving City water service. Renters or tenants must have written approval from the property owner. Timelines • Program applies to clothes washers purchased from July 1, 2015 thru June 30, 2016. Products purchased prior to July 1, 2015 or after June 30, 2016 will not qualify for this rebate program. • Rebates are available for purchasing qualified washers until June 30, 2016, or until funds are depleted, whichever comes first. • All rebate applications must be postmarked no later than 90 days after purchase date. • The qualifying clothes washer must remain at the installation site for a minimum of six months after installation date. Clothes Washer (qualifying for rebates) • Must be an Energy Star label appliance which meets Consortium for Energy Efficiency (CEE) standards for energy and water consumption standards. • Only Tier 3 high-efficiency clothes washer models on the current CEE list are eligible (CEE Tier 1 and Tier 2 clothes washer models do not qualify for this program). No rebates are offered on clothes washers that contain silver ion technology. • Qualifying units must have a Water factor of 5 or less. • The list of eligible clothes washers and washer rebate values is subject to change. Rebates • Rebates are subject to onsite compliance inspections verification by the City of Modesto Water Conservation Program. • Clothes washer installation cost and new construction are not rebated. • Level incentive is $100 per qualifying unit. Rebate cannot exceed the purchase price of the new unit. • There is a limit of one clothes washer per household per five year period. Application and Rebate Approval or Denial • You must provide the original itemized sales purchase receipt. The receipt must list purchase price, manufacturer, model number, and purchase date. • Incomplete and unsigned applications will not be approved and will not be returned. • Customers must fulfill all program guidelines to be eligible for incentives. Other Considerations • Qualified washer must be installed in the City of Modesto Service Area and must remain at the installation site for a minimum of six months after installation date. • The rebate program is not responsible for material lost by mail. • Submission or possession of a rebate application does not guarantee receipt of a rebate. • Rebates are processed on a first come, first served basis and will end when program funds are depleted. • Rebates are available for purchasing and installing qualified washers until June 30, 2016, or until funds are depleted, whichever occurs first. • This program shall at all times be subject to change or termination without prior notice. Clothes washers that are units leased, rebuilt, rented, received from warranty or insurance claims, exchanged, won as a prize or have had new parts installed in an existing unit, do not qualify for a rebate.